Incident description

An individual was assisting a researcher with setting up equipment for a research project. Part of this process involves counterbalancing the machine by selecting different weight combinations of steel plates and securing them to one side of the machine. The individual manually lifted a 45 lb. steel plate then carried it approximately 5.5 feet to the location it was to be mounted to the equipment. It is believed the individual was attempting to raise the weight to place it over the top of the mounting bolts to secure it to the machine. The individual was lifting the plate onto its mounting position using magnetic lifting handles. Both handles were secured to the top of the plate. One or both of the magnets disengaged and the plate fell on the individual's foot. The height of the top of the mounting bolts is approximately 60 inches above ground level. The individual was standing at ground level at the time of the accident and was not using the step stool that is located in the area for the plate mounting task.

The department completed the LHAT for the personal protective equipment (PPE) hazard assessment. At the time of the accident protective footwear was not required PPE. It was confirmed that the injured individual was not wearing protective footwear. 

What went right?

1. The department housed the steel plates made of different weights on a movable cart that could be rolled next to the location where the plates must be mounted. This is meant to reduce the risk of sprains/strains and struck by object risks associated with manual lifting and carrying.

2. The department has a step stool available near the machine to reduce the the need for individuals to lift the steel plates above shoulder height. 

3. The department had assigned responsibility for training on the use of the equipment and provided informal hands-on instruction.  While informal training does not meet UC Davis guidelines or Cal/OSHA requirements it is still an effort on the part of the department to reduce risk associated with this process. 

4.  EH&S was notified of the accident through the on-call process and the Employer's First Report was completed.

5. The department completed a thorough investigation of the accident. They are working to implement the most effective controls based on the hierarchy of controls. The implemented controls stages include immediate controls to reduce the risk of another accident occurring while examining long-term controls that would be the most effective means of control. 

6. The department included individuals that use the equipment as part of the solution discussion to identify and implement effective controls that will not create unforeseen consequences.

What should have been done differently?

There were no formal, written procedures for the loading and unloading of weights as part of the counterbalance process. This portion of the manual handling task had not been formally examined to identify hazards and controls. Hazard assessment tools such as a job hazard analysis had not been conducted for each step of the process, including cart placement, plate sorting, maximum plate weight, manual lifting/carrying/lowering, crane use, step ladder use, and securing the plates to the machine. Since hazards associated with this task were not identified, safe standard operating procedures were not created or trained on. 

How to prevent this in the future

Engineering/Equipment Control Measures
• The 45-lb. counterbalance plate was removed from inventory. The remaining plates all weigh less than 25 lbs. 
• Crane use: The plates will be wheeled to the machine using the cart. The cart will be positioned directly adjacent to the section of the equipment where the plates will be mounted. The machine is designed with a top hatch that can be opened directly over the plate cart. This opening will allow the jib crane access to the plates so they can be lifted and positioned on the machine using the crane. There may still be a need for manual manipulation of the plates to get holes aligned with the bolts, but this change will greatly reduce the risks associated with manually lifting and positioning the plates. 

Administrative Control Measures
• The department will be working with EH&S to conduct a formal job hazard analysis for this task and to develop formal safe standard operating procedures. The department will implement training based on the standard operating procedures. 
• The plate handling process will be modified to require direct handling of the smaller plates, either by hand or by jib crane, with an emphasis on not relying on magnets to lift and lower the load without backup. 
• Magnetic handles will be used to sort plates on the cart but not for carry plates.
• The department is adding a handle on the exterior of the of the machine to allow for three points of contact when using the step stool.

Personal Protective Equipment
It was recommended by EH&S that the department examine the use of footwear that includes metatarsal protection as part of their personal protective equipment hazard assessment.